HospitalInspections.org

Based on document review, record review, and staff interview, the Hospital failed to notify patient family members (Patient #1) at the time of an injury that occurred while the patient was hospitalized. Failure to notify family members has the potential for the provision of ongoing unsafe care or accusations of the provision of unsafe care.

Findings include:

-Document review of the Hospital policy titled "Disclosure of Unanticipated Outcomes" effective date 03/13 showed the purpose is to involve the patient with care and communicate information of unanticipated outcomes to the patient and representatives. The document further states patients are entitled to information about unanticipated outcomes of care and disclosure to the patient and/or family should be made as soon as practical.

Review of Patient #1's discharged medical record on 06/25/18 at 11:30 AM showed he was admitted to the Hospital on 04/25/18 with a diagnosis of neurological deficit (weaker function of the brain, spinal cord, muscles, or nerves) associated with progressive weakness and failure in his ability to perform activities of daily living (ADL's) independently. Comorbidities included coronary artery disease (CAD) (narrowing of the arteries of the heart), chronic obstructive pulmonary disease (COPD) (obstruction of the airways) requiring steroid treatment, steroid induced myopathy (muscle weakness), and hypertension (elevated blood pressure).

A nursing note on 04/27/18 at 8:53 PM by Staff B, Registered Nurse (RN) stated Staff H, Certified Occupational Therapy Aid (COTA) notified her of discoloration of the 2nd toe on the right toe that Staff H had noted after showering Patient #1, who had complained about the toe. Staff B, RN stated the wound site was cleansed with wound cleanser and a dressing was applied per the Hospital wound care guidelines which were to cleanse the toe every three days and apply mepitel, purocol, and a dry dressing.

A nursing note written 4/29/2018 at 4:10 PM by Staff F, RN, stated Patient #1's family visited him and expressed concern about his right first and second toes. The family stated they wanted to be notified of any additional changes in Patient #1's condition and provided updated phone numbers for this purpose. Staff F, RN also stated she spoke with Staff M, Physician and alerted him that the injured toes appeared bluish in color however Patient #1 stated he thought they "look better today than they have been". She further stated that Staff M, Physician planned to assess the foot tomorrow and the nursing supervisor was made aware of the appearance of the toes.

During an interview on 06/27/18 at 10:45 AM, Staff B, RN stated she was made aware of the toe injury by Staff H, Certified Occupational Therapy Assistant (COTA) and it was bleeding at that time. Patient #1 told Staff B, RN he did not know how it was injured. She notified Staff M, Physician. She stated she did not contact the family about the injury. Patient #1's family were present the following day and Staff B, RN explained that he had an injury of an unknown cause and that she had assessed and treated the wound and notified the physician. She further stated the family did not react but "looked upset." She also stated she did not know if the Hospital has a policy or procedure guiding staff when to notify families of changes in patient status. She confirmed she notified Staff Y, RN, Supervisor who assessed Patient #1's wound as well. An incident report was completed.

During an interview on 06/27/18 at 1:54 PM, Staff T, CEO clarified suboptimal outcomes as something that is treated in a minor nature as in when the staff may bump a patient arm and a scratch occurs or a bruise or it would be care for something like would happen in our home. She stated that it would vary in some situations and they would have to review components of each situation and explained that if they did not know how something occurred it would not be relevant to all situations. She further stated the above policy is intended for the middle ground situations and not over something with a lift, hitting a knee on the bed, and transfers. This policy would not be in regard to skin tears and scrapes.
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